How to talk about ‘psychosocial’ issues with people experiencing chronic pain

If you’ve been following the discussion on my last post about selecting the right person to receive spinal injections (see here), you’ll see a doctor challenged with how to begin to talk about psychosocial issues with patients without the patient thinking ‘she thinks it’s all in my head’!

It’s a really common problem, IMHO. How to communicate to a person who feels anxious, somewhat disbelieved, and definitely fearful that someone, somewhere is going to suggest that if they ‘pull themselves together’ they’ll be all right!

The problem is that I haven’t found a lot of very good evidence to provide direction as to the best way to actually DO this, so I’m going to rely on a few years of experience – and invite you to have a go.
The underlying principles that guide me in this are drawn from motivational interviewing, especially the role of reflective listening, and being aware of the suspicion that people have about being judged about the reality of their pain.

I wonder whether some of the reluctance people have about acknowledging the psychosocial is that we may be inadvertently suggesting these issues ’cause’ pain, which immediately suggests to the person that they are being judged as ‘not coping’. So, perhaps coming alongside (metaphorically speaking) and acknowledging the distress the person could be having is one way to begin to explore these factors.

Some phrases that might help in this:

‘It sounds like the past few weeks have been pretty tough for you – can I ask, how are you feeling in yourself?’

‘When you start talking about your pain it makes me wonder how you’ve been managing day-to-day?’

‘Sometimes people find their pain disturbs their sleep – is it OK if we talk about this for a while?’

‘Would it be all right if we spent some time looking at how your pain is affecting you at work?’

‘Pain is invisible, and no-one can tell how much pain you’re actually in, would be it OK with you if we talked about what that’s been like for you?’

I think a couple of techniques can break the ice – but most importantly, an attitude of sensitive inquiry and acceptance. Pain is a stressor, irrespective of the ’cause’ – and remember that most pain has a physical initiator, even if it’s not being maintained by nociceptive input.

One of the techniques is to ask permission to discuss how the person has been coping/managing/feeling in him or herself. By being respectful of how ready the person is to talk about this area can open the doors to them being open with you.

Another is to reflect what they’ve been saying to you to demonstrate your understanding. By doing this you show you have been listening, and if you’ve got it slightly wrong, it allows the person to correct you. For example: ‘Let me summarise what I think you’ve been telling me: no-one has been able to tell you why your pain is going on, it’s not responding well to medications, and you’re feeling pretty frustrated about the process of diagnosis. Have I got that about right?’

Open-ended questions such as ‘How have you been sleeping?’, ‘What’s it been like for you at work?’, ‘How are you managing with this pain at home?’ give the person an open door to start talking about the impact of pain.

Even if you think the person’s pain behaviour is ‘exaggerated’, or their disability is more than what you would expect if you had their problem, suggesting in any way that this is something they are choosing to do deliberately won’t help bring them onside.

Remember ‘resistance’? This happens when people feel they are being asked to move beyond their stage of readiness. Our job is to help them move only one step forward along that continuum – and that will only happen if we’re respectful and genuinely believe that they have arrived at the position they’re in because they’ve been making what they think are the best decisions at the time. We may not agree with those decisions – but our job is to help the person identify the ‘good’ and ‘not so good’ about their position, and to provide information (when invited) so they can make new choices.

To reduce resistance, the best step is to reflect empathically with the person, even admitting that we might be wrong! And then suggest helping them look at what is working and not working about their current situation. This might mean agreeing that they might be feeling confused, frustrated, even fed up with suggestions that they might be able to cope better with their pain if they had some help from a psychologist, occupational therapist, social worker or nurse. Asking their permission to expand on why these people might be able to help will give the person a choice – and being offered this is what people respect.

I’ll post some more about this topic tomorrow – you can see it’s dear to my heart!

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2 comments

You might realize there are many reasons why a social work assessment ought to be considered early on, not just as a referral source after the medical assessment. A social worker as part of the team offers a psychosocial perspective. I ought to know. I am one myself.

My physiologist’s first two questions were: How’s your weight? and Do you live with others or by yourself? Such good questions.

Great points Esther. If only we were able to have more social workers involved in health care! In New Zealand, ACC (workers’ compensation) doesn’t allow social workers to be part of the clinical team working with their claimants, which is a shame. Although there are many training schemes in New Zealand, not all social workers are qualified formally, nor registered. I’ve worked with some fabulous social workers, and the ones in the team that I’m with now – excellent!